Transition to WVCHIP

1. Transition to WVCHIP For Medicaid and WVCHIP Dual Providers

2. WVCHIP Transition Beginning July 1, 2019 KEPRO will become the Utilization Management Contractor (UMC) for the West Virginia Children’s Health Insurance Program (WVCHIP) and HealthSmart will no longer be the vendor. • There will be a transition period – HealthSmart will process ALL prior authorization (PA) requests received through COB 06/24/2019. There will be a “blackout” on WVCHIP requests 06/25/2019-06/30/2019 where no WVCHIP requests will be processed by either HealthSmart OR KEPRO. • KEPRO will begin processing requests on 07/01/2019. • Any PA Requests submitted to HealthSmart after June 24th will not be accepted and all documents received by HealthSmart will be shredded. Provider will be contacted by phone or receive a return notice by fax. • Any PA issued by HealthSmart will be honored by DXC (claims payer) provided the date of the service is covered by the PA and there are sufficient units to cover the service. There is no need to get a new PA from KEPRO for a service already authorized. • Should a new service or additional service be needed after a PA expires, a prior authorization request must be submitted to KEPRO for medical necessity determination. • If a service is not conducted (e.g. rescheduled beyond valid dates of authorization), a prior authorization request must be submitted to KEPRO for medical necessity determination.

3. How Will WVCHIP be Integrated? • KEPRO’s business hours will remain the same 8AM-5PM Mon-Fri. • Use of direct-data-entry (DDE) system whenever possible. C3 remains available 24/7 for both Medicaid and WVCHIP prior authorization request submission. • Additional users can be added as necessary by providers to address submission of WVCHIP prior authorization request. • Fax forms for WVCHIP have the WVCHIP logo and have been adapted to WVCHIP. They are available on the wvaso.kepro.com website in the WVCHIP providers section. These need to be completed entirely for staff to key requests- incomplete forms will be faxed back and may delay PA. • As with Medicaid, telephonic requests will only be accepted for emergent situations for WVCHIP members. • Authorization letters will not be sent to the WVCHIP members. Authorization notification to providers is the same as for Medicaid authorizations.

4. What Will Remain the Same? • WVCHIP Benefits • Covered services • Services requiring prior authorizations • Services with special instructions • Fee schedules • WVCHIP Member application and enrollment • WVCHIP Provider enrollment • DXC will remain the claims payer • All claims billing issues and questions related to authorization numbers issued (HealthSmart or KEPRO authorizations) should be addressed to DXC.

5. New WVCHIP Master Code List • Like the Medicaid Master Code List the WVCHIP Master Code List (MCL) provides a crosswalk of the WVCHIP benefit to the existing medical system and will direct you regarding how to submit requests (DDE or fax). • This list will include the codes that require prior authorization and codes with service limitations/special instructions. • There are some codes that are not eligible for direct-data-entry (DDE). These specific codes will need to be submitted via fax on the appropriate authorization request form. • It is recommended that codes available to be submitted via the DDE system are submitted in that manner. • This is recommended due to the DDE system’s validation features, tracking ability, efficiency, and timeliness. • The WVCHIP Master Code List (MCL) will be available on the www.wvaso.kepro.com website in the WVCHIP Section.

6. Example of WVCHIP MCL

7. Submitting Requests DDE v. Fax • Some codes in the WVCHIP benefit are not available in C3- the MCL indicates fax submission for these codes • Appropriate form must be selected and completed in its entirety and faxed to the number on the form-incomplete forms will be faxed back to provider requesting the necessary information • Requests will be keyed by KEPRO staff in the order received and sent to the clinical queue for review • When the MCL shows a code can be requested DDE you will be able to create and submit the request • This method provides guidance to ensure all required information for successful review is included • This method prefills provider information, member demographics and other information without keying • Goes directly to queue for review

8. Sample of PA Form

9. Telephonic Emergent Requests • As with Medicaid requests, KEPRO will only allow telephonic review for WVCHIP emergent requests. • Per WVCHIP, a medically urgent request is: • a delay could seriously jeopardize the life or health of the member or, • the ability of the member to regain maximum function or, • in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. • Emergent requests can be submitted by DDE or fax, but are limited for phone review. Areas in which a request can be submitted by phone are: • Inpatient Services • Non-elective Outpatient Surgery • Emergent Lab/Imaging/Radiology requiring PA • NOTE: Some review areas do not recognize medically urgent requests. In these instances it is not a choice in the admission type dropdown. For those review areas that recognize medically urgent (e.g. inpatient) each admission type has a medically urgent choice (e.g. direct admission OR direct admission-medically urgent). Requests not meeting the medically urgent definition WILL NOT be clinically reviewed as medically urgent.

10. Prior Authorization Request Submission • The current submission process remains the same except WVCHIP eligibility is now available in C3. • BE SURE YOU CHECK THE WVCHIP MCL BEFORE PROCEEDING! If the code is not located in C3 you will need to fax in the request. The WVCHIP MCL will indicate how the authorization request will need to be submitted.

11. About KEPRO Authorizations Issued • When it is indicated that a code is fax only, C3 will generate an authorization number of all zero’s. • KEPRO staff will generate a manual authorization number (WXUTH#), and will post the manual authorization number in the last annotations box on the Summary and Submit screen. Please use this authorization number on your claim. • Please do not use the all zero’s or use the authorization request ID on your claims. Your claim will be denied. • Prior Authorization DOES NOT assure eligibility or payment of benefits under WVCHIP. • PA requests will not be reviewed by KEPRO for providers who are not enrolled with WVCHIP

12. Example of all Zero Authorization Number

13. About KEPRO Authorizations Issued

14. Reconsideration Options The WVCHIP Reconsideration process will mirror the current Medicaid process. • Expedited Reconsideration – Expedited reconsiderations are only to be requested if the authorization request is medically urgent. • Peer-to-Peer (Level 1) – This is a physician to physician discussion available to providers to present additional clinical information or medical necessity information following initial denial. The Level 2 reconsideration is STILL available after the Level 1 review. The provider can elect to go directly to Level 2 but cannot go back to Level 1 once a Level 2 review has been completed. • Reconsideration (Level 2) – In the KEPRO system this is the same as the Peer-to-Peer defined in the WVCHIP benefit.

15. Training and Technical Assistance • We offer training via webinar, phone, and various materials. • These are offered to make submitting online for Prior Authorization an easier process for providers. • There are also annual reviews/trainings available to providers. • Provider training is also offered for various provider groups. • Each PowerPoint presentation from the provider trainings are posted to the http://www.wvaso.kepro.com in the Manuals and Reference Materials section of our website.

16. All Trainings Available Before Transition • For WVCHIP ONLY (NEW) providers: • 6/18/2019 9AM-12PM • 6/20/2019 1PM-4PM • 6/26/2019 9AM-12PM • 6/27/2019 1PM-4PM • For Medicaid enrolled providers who are ALSO WVCHIP (EXISTING) providers: • 6/18/2019 2PM-3:30PM • 6/20/2019 9AM-10:30AM • 6/26/2019 2PM-3:30PM • 6/27/2019 9AM-10:30AM

17. New WVCHIP PA Contact Information Prior Authorization Request Fax Numbers (WVCHIP fax forms indicate the appropriate fax number) • 844.633.8426 - Bariatric/Inpatient/Inpatient Rehab Under 21/ Organ Transplants • 844.633.8427 - Outpatient Surgery • 844.633.8428 - Imaging/Radiology/Lab • 844.633.8429 - Cardiac & Pulmonary Rehab/DME/Orthotics & Prosthetics • 844.633.8430 - Home Health/Hospice/Private Duty Nursing • 844.633.8431 - Audiology/Speech/Chiropractic/ Dental/Orthodontic/Podiatry/PT/OT/ Vision • 866.209.9632 - Modification Requests/EPSDT/ Out of Network WVCHIP Phone: 1-888-571-0262 WVCHIP Fax: 1-866-438-1360 WVCHIP Email: WVCHIP@KEPRO.COM

18. KEPRO WVCHIP PA Contact Information